Attentional Bias Modification: Development and testing of a school-based "Cognitive Vaccine" for the reduction and prevention of child anxiety

Childhood anxiety problems are so serious and common that the need for early intervention and the promotion of emotional well-being in children has been the focus of several UK government reports. Childhood anxiety often continues into adolescence and adulthood, and is associated with difficulties at school and with impaired social functioning and peer problems. It is also a major risk factor for experiencing other psychological and physical health problems. Targeting children at risk of developing anxiety, could lead to prevention programs aimed at helping vulnerable children, especially during periods of high stress. Preventative interventions at this early stage can set the individual back onto a healthy path avoiding considerable later distress and cost to both the individual and society. By identifying and understanding the factors that make some children more vulnerable to developing anxiety, we should be able to treat them and prevent them from experiencing anxiety. In this way, we can develop treatments that act like a vaccine - increasing children's immunity against feeling very anxious when faced with stress. One factor that is known to be important for developing anxiety is the way people's brains process emotional information, such as pictures of facial expressions or emotional words. There is evidence that children who have elevated anxiety pay greater attention to threatening information, for example an angry or disgusted face. Targeting how children pay attention to emotional information may be a promising way of preventing and treating childhood anxiety.

A simple method for changing how children pay attention to emotional information already exists; the attentional bias modification task (ABM). ABM is a simple computerised task that trains children to get into the habit of not paying attention to threatening information. In this project, we want to assess whether ABM may act as a vaccine against feeling anxious, in response to a stressful experience such as having to do a presentation in front of an audience, or taking end of year exams. We are going to perform three studies with a group of children aged 9 to 11 years who are experiencing higher than normal levels of anxiety. All three studies will compare the effect of ABM with an inactive control condition not designed to change how children pay attention to emotional information. Study 1 will establish the type of emotional information it is most useful to direct children's attention to. Specifically, we are interested in whether it is most effective to make children pay greater attention to positive or neutral information. Study 2 will provide information on the best way to deliver the treatment; that is how regularly the children should complete the treatment. Study 3 will test how effective ABM is in preventing anxiety, by measuring whether it affects how children pay attention to emotional information, and how much anxiety, children report generally. We will measure the effects of ABM on children's anxiety response to an experimental stress task (performing a talk and doing a difficult maths problem). We will also explore the effects of ABM on children's anxiety surrounding the end of year national curriculum exams (SATs), which we know that many children find stressful. These measures will tell us whether ABM is likely to prevent children from feeling anxious and whether we are ready to test ABM with children who are very anxious in large scale clinical trials.

Childhood anxiety disorders are highly prevalent and place a significant health and wealth burden on the individual and wider society. Targeting at-risk children through prevention programs, especially during periods of high stress could be an effective means of intervening to reduce this burden. Attentional biases to threat represent a causal vulnerability factor for experiencing anxiety. Interventions that target attentional biases should act as a cognitive vaccine, increasing immunity against experiencing anxiety to stress. The current proposal considers whether a cognitive manipulation, which modifies dysfunctional attentional biases in children at elevated risk for feeling anxious, represents an effective vaccine against experiencing anxiety.The proposed research will assess the efficacy of a novel computerised intervention designed to alter attentional bias, the attentional bias modification task (ABM). Study 1 will establish which type of stimuli it is most useful to train children's attention to. Study 2 will establish the best time-line by which to deliver the protocol. Study 3 tests whether ABM can act as a vaccine, enabling children to cope better in response to a lab-based and a naturalistic stressor. The efficacy of the manipulation will be assessed using established measures of attentional bias and self-report, observational and physiological measures of susceptibility to experiencing anxiety in response to lab-based and naturalistic stress. All experiments will employ a randomised mixed design with participants being allocated to active ABM or a control group. Outcome measures will be assessed at multiple time points. This project will provide proof of concept data on the use of ABM as a preventative intervention before deploying it in larger scale clinical trials. Findings would have implications for our understanding of the cognitive processes underpinning child anxiety and for reducing health and wealth burdens through its prevention and treatment.

Who will benefit from this research?: This research will be of interest to a wide range of audiences, with the main beneficiaries being children and their parents, academic scientists and mental health and educational practitioners. The research complements initiatives such as the Children and Young People's Mental Health Coalition, which campaigns on behalf of children to effect change in policy and practice that will improve their mental health and well-being. The findings from this work will also feed into current government initiatives, for example the child version of the NHS initiative "Increasing Access to Psychological Therapy" (IAPT) for the treatment of anxiety/depression.

How will they benefit from this research?: The proposed work has clear wealth and health implications. Child mental health problems are estimated to cost the UK taxpayer an extra £63,000 per child (between the ages of 10-28) with a total cost to the economy and society of £150,000 per child over their lifetime (Layard, 2008). The proposed work directly feeds into government initiatives to realise the benefit of early intervention and prevention to increase the effectiveness of public services, enhance quality of life, and save money (Department of Health, 2010; The Government Office for Science, 2008). The proposed work will identify the potential of ABM to act as a "cognitive vaccine" (Holmes et al., 2009) to immunise high-risk children from experiencing anxiety in response to stressful events. Given the considerable suffering, dysfunction and poor prognosis associated with anxiety it is highly beneficial to intervene during childhood and thus disrupt long-term cycles of maladaption. As such, the development and testing of novel methods for prevention and early treatment efforts should be a priority, especially in children at risk of developing anxiety. Preventative interventions at this early stage can set the individual back onto a healthy trajectory avoiding considerable later distress and cost to both the individual and society. We anticipate that the outputs of this work would feed into health policy making within 3-5 years of the work commencing.

Academics: The proposed work will shed further light on the causal role of attentional biases in child anxiety, thereby informing cognitive models of childhood anxiety. We will also begin to elucidate the mechanisms underlying the anxiolytic effects of ABM. These impacts will be realised within the lifetime of the project.

Mental health and educational practitioners: The proposed work will increase confidence in the use of ABM as a preventative or early-treatment intervention. It will highlight the need for practitioners to focus on early, automatic cognitive biases in the development of child anxiety, which are not easily targeted with existing treatment protocols (e.g. CBT). These outputs of the proposed work are likely to feed into health and education practice within 2-5 years of the work commencing.

End Users: Parents and children will benefit from an intervention, which acts to reduce risk for experiencing anxiety in response to stressful and unavoidable challenges. Given the escalating effects of child anxiety disorders (via school absence, and associated lowering of social confidence and academic development) it is crucial to increase access to appropriate and effective prevention and treatment programs. Those participating will benefit directly, while we hope that in the longer term ABM will become widely available as a preventative and/or early treatment intervention. ABM may be particularly appealing to children due to its computerised format and its ability to be administered in a variety of settings with minimal external input. In this way, ABM may prove to be particularly cost-effective too. It may also benefit those children who do not wish to engage with traditional treatment formats, or who respond poorly or drop-out. These impacts will be realised within 3-5 years.